Provider Demographics
NPI:1699978601
Name:TUTTLE, TAMARA (PA-C)
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:TUTTLE
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:94180 2ND ST
Mailing Address - Street 2:
Mailing Address - City:GOLD BEACH
Mailing Address - State:OR
Mailing Address - Zip Code:97444-8733
Mailing Address - Country:US
Mailing Address - Phone:541-247-3940
Mailing Address - Fax:541-247-3116
Practice Address - Street 1:94180 2ND ST
Practice Address - Street 2:
Practice Address - City:GOLD BEACH
Practice Address - State:OR
Practice Address - Zip Code:97444-8733
Practice Address - Country:US
Practice Address - Phone:541-247-7047
Practice Address - Fax:541-247-0123
Is Sole Proprietor?:No
Enumeration Date:2007-06-07
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA150522363A00000X, 363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR161133OtherNBMC GROUP DMAP
ORR0000WFBTVOtherNBMC GROUP MEDICARE
OR930635514OtherNBMC TAX ID FOR BILLING
OR1407812365OtherNBMC GROUP NPI
UT63009641206OtherSTATE OF UT LICENSE NUM
ORPA150522OtherOREGON STATE LICENSE #